Comprehensive Plan of Care

Option 1
Patient Setting:
28-year-old female presents to the clinic with a 2 day history of frequency, burning and pain upon urination; increased lower abdominal pain and vaginal discharge over the past week.
HPI
Complains of urinary symptoms similar to those of previous urinary tract infections (UTIs) which started approximately 2 days ago; also experiencing severe lower abdominal pain and noted brown
fouls smelling discharge after having unprotected intercourse with her former boyfriend.
PMH
Recurrent UTIs (3 this year); gonorrhea X2, chlamydia X 1; Gravida IV Para III
Past Surgical History
Tubal ligation 2 years ago.
Family/Social History
Family: Single; history of multiple male sexual partners; currently lives with new boyfriend and 3 children.
Social: Denies smoking, alcohol and drug use.
Medication History
None
Trimethoprim (TOM)/ Sulfamethoxazole (SMX) -Rash
ROS
Last pap 6 months ago, Denies breast discharge. Positive for Urine looking dark.
Physical exam
BP 100/80, HR 80,
RR 16,
T 99.7 F, Wt 120,
Ht 5’ 0”
Gen: Female in moderate distress.
HEENT: WNL.
Cardio: Regular rate and rhythm normal S1 and S2.
Chest: WNL.
Abd: soft, tender, increased suprapubic tenderness.
GU: Cervical motion tenderness, adnexal tenderness, foul smelling vaginal drainage. Rectal: WNL.
2
EXT: WNL. NEURO: WNL.
Laboratory and Diagnostic Testing
Lkc differential: Neutraphils 68%, Bands 7%, Lymphs 13%, Monos 8%, EOS 2%
UA: Starw colored. Sp gr 1.015, Ph 8.0, Protein neg, Glucose neg, Ketones neg, Bacteria – many, Lkcs 10- 15, RBC 0-1
Urine gram stain – Gram negative rods
Vaginal discharge culture: Gram negative diplococci, Neisseria gonorrhoeae, sensitivities pending Positive monoclonal AB for Chlamydia, KOH preparation, Wet preparation and VDRL negative
Option 2
Musculoskeletal Clinical Case
HPI
A 40-year-old Asian American male, who works as a roofer, complains that three days ago he was lifting a heavy object at work, following which he got low back pain. The pain is in the middle of the
back near his waist. The pain increases when he bends forward and he is experiencing numbness and tingling in the toes of his right foot. He has had similar symptoms before, but it has not been so
bad in the past. This is the worst he has had because in the earlier instances, he has never had the tingling sensation in his right foot before.
In the past, he got better with rest and some Ibuprofen. He is worried that he will not be able to continue his work and make money. He is out of work as a result of the pain. He has a lot of di
culty getting sleep at night. He has started taking some of his friend’s medication and it seems to help.
He has pain in the mid lumbar area, which radiates to the right buttock. He also has numbness and tingling down the back of his right thigh to his toes. The pain and numbness has been increasing
since the problem started three days ago. He has tried over-the-counter Ibuprofen and some stretching exercises, but it does not seem to help. He has not sought any medical care yet. In the past,
the pain had just gone away, but this time the pain is persistent. There is a gradual worsening of his symptoms and he is concerned about the pain that has been increasing steadily over the past
three days. He is wondering whether he has a herniated disc. His major concern is that he has no health insurance and will be missing work.
PMH
He has had similar pain in the past, but it was not so severe. He saw a chiropractor around two or three years ago and that gave him some relief. Otherwise, the patient has no chronic medical
problems. He does not seek medical care on a routine basis.
He has had no diagnostic measures in the past. He has never had any blood work reports, CT scan reports, X-ray reports and so forth done in the past. He has been gaining weight over the past few
years and does not do any stretching exercises before
work. Patient does not have any other risk factors. There are no records of any past surgeries. He has neither had any signi cant illnesses in the past nor any hospitalizations.
ROS
Pain in the mid lumbar area radiating to the right buttock. There is a tingling sensation that goes down the back of his right thigh to the toes. He does not have urinary or bowel incontinence. No
nausea, vomiting, or fever. He denies abdominal pain and pain with urination. There is no gross hematuria.
Page 1 of 4 NSG6001 — Advanced Nursing Practice I ©2015 South University
MEDICATIONS
Patient does not take any prescription medications, only over-the-counter Ibuprofen. He is using 800mg of Ibuprofen every four hours. Patient is compliant with the prescribed regimen; in fact, he
could be using too much. Patient is seeking care because of the increasing pain. He has tried chiropractic manipulations in the past for low back pain.
ALLERGIES/REACTIONS
He is allergic to Penicillin. It has caused a rash in the past.
SOCIAL HISTORY
This patient works for a local roo ng company and makes $30,000.00 per year, which is just a little over the minimum wage. He has a high school education certi cate and makes just enough money to
get by. He has no health insurance. The patient feels that the last thing that he wants to do is spend money on healthcare. He feels his body will get better on its own, and so he can just keep
working. He made the appointment at this outpatient clinic because his friends told him about it. He was not sure where to go for help. He has decreased access to healthcare because he is not aware
of the services available. The patient has had essentially no healthcare to date. The patient states that he is starting to realize that his body will not last forever at his current position as a
laborer.
The patient is divorced and thinks he was a failure as a husband. He is behind in alimony payments. His wife is alive and well without any medical problems. They do not communicate anymore. They
have no children. He would like to try and get back together with her, but she refuses to speak to him. He has been holding himself back from expressing the amount of stress he has in life for many
years. He thinks he is becoming depressed as a result of this. His parents still live in the area and he sees them every weekend. He has friends from work and they do social things together. The
patient has not sought any emotional support from anybody. There is no element of family dysfunction. He becomes easily stressed out. He lives in social isolation from his community. The patient
has always taken his health for granted and not thought much about it in the past.
HABITS
Smoking: Non smoker
Alcohol: Drinks at bars on weekends to excess with his friends Substance abuse: He smokes marijuana.
DIET HABITS
He skips breakfast and eats at fast food restaurants twice every day. He sips co ee and ca einated beverages throughout the day. The patient feels that his job gives him enough exercise and so he
need not do anything else. He plans to go on a “diet” soon to lose the weight he has gained over the past few years, but is not sure about the diet he is going to follow.
WORK HABITS
The patient works as a roofer. He has had other labor-intensive jobs in the past that do not require an
NSG6001 — Advanced Nursing Practice I Week 5: Musculoskeletal Clinical Case
NSG6001 — Advanced Nursing Practice I Week 5: Musculoskeletal Clinical Case
educational background. He does not enjoy his job. He knows it is a dead end job and wants to go to school. He is originally from United States and lives in a suburban community where resources are
easily accessible, but he is not aware of them.
FAMILY HISTORY
Both parents have hypercholesterolemia. His 65-year-old father has prostate cancer. Both parents are being treated with medications for their high cholesterol levels. He has no siblings. There is a
remote history of heart disease in his relatives.
PHYSICAL EXAMINATION
Vital Signs: Ht: 6’; Wt: 220; WC: 40; BP: 120/78; T: 97 po; P: 92 and regular; R: 18 non-labored HEENT: WNL
Lymph Nodes: None
Lungs: Clear
Heart: RRR without murmur
Carotids: Not examined
Abdomen: Android obesity, otherwise benign
Rectum: Not examined
Genital/Pelvic: NA
Extremities, Including Pulses: 2+ pulses in the lower extremities
Neurologic:
Mental Status: Alert and oriented
Cranial Nerves: II – XII intact
Motor Strength: Upper extremities equal strength 5/5.
Lower extremities: decreased strength of right leg with resisted extension; patient complains of pain in posterior thigh.
Sensation (light touch, pin prick, vibration, and position): Decreased sensation of right leg along L5 : S 1 dermatome to pin prick stimulation compared with the left.
Re exes: DTRs 2+ in upper and lower extremities
Cerebellar function intact—Romberg test is negative; heel-to-toe walking is steady. Postive straight leg raise on the right at 20 degrees.
NSG6001 — Advanced Nursing Practice I Week 5: Musculoskeletal Clinical Case
LAB RESULTS/RADIOLOGICAL STUDIES/EKG INTERPRETATION
Lab Results
CBC: WNL
UA dip stick: WNL
Radiological Studies
Plain lm of lumbar spine: loss of disc height at L5 to S1. Mild degenerative changes of lumbar vertebrae.
MRI: moderate disc bulge at L5: S1. EKG: Not performed

pick one of these cases to analyze and create a comprehensive plan of care for acute/chronic care, disease prevention, and health promotion for that patient and disorder. Your care plan should be
based on current best practices and supported with citations from current literature, such as systematic reviews, published practice guidelines, standards of care from specialty organizations, and
other research based resources. In addition, you will provide a detailed scientific rationale that justifies the inclusion of this evidence in your plan. Your paper should adhere to APA format for
title page, headings, citations, and references. The paper should be no more than 3 pages typed excluding title page and references.